Accelerating the Shift to Downside Risk in Medicare Accountable Care Organizations: Effects on Clinical Quality and Costs among Older Patients

项目摘要 老年患者接受分散的医疗保健，其质量和成本各不相同。为了解决这个问题， 医疗保险和医疗补助服务中心（CMS）开发了责任护理组织（ACO）。ACOs 鼓励提供者共同努力，同时注意他们的支出。的评价 医疗保险共享储蓄计划（MSSP）-CMS最大的ACO计划-表明，参与 组织提高了老年患者的护理质量。尽管如此，它们的成本仍然很高， 没有足够的“游戏中的皮肤”。大多数ACO都有合同，其中他们分享一小部分 当他们将年度成本降低到基准以下，但 如果它们达不到则受到惩罚（即，没有任何风险）。如果没有下行风险的财务威胁， ACO没有太多理由去创新和提高效率。因此，CMS在2009年宣布了“成功之路”。 2018年12月，要求目前的MSSP ACO在短短一年内转向下行风险。然而，在这方面， 如此迅速的转变可能是有害的。MSSP是自愿的，许多从事 有意义的护理重新设计可能还没有准备好承担必须偿还CMS数百万美元的可能性， 而是离开程序。事实上，今年7月面临续约的ACO中有40%退出了。未经 共享节约的潜力，退出的ACO可能会剥离其数据系统和所需的协调能力 用于人口健康管理，维持成本高昂。反过来，ACO的病人可能会遭受更低的痛苦， 护理质量和更高的成本。留在MSSP的决定也可能产生意想不到的后果。 ACO可能会采取成本控制策略，如有利的患者选择。他们也可能会限制他们的注意力 CMS要求的指标（以牺牲其他临床重要指标为代价）。这些举动会伤害老年人 从助理文书主任那里获益最多的病人在这方面，我们提出了一个综合的定性和 定量研究有三个具体目标。1)审查有关MSSP参与的决定， 这些决定对一个组织在启动后提供护理的方法的影响 通往成功之路。使用行政数据，我们将有目的地抽样12个没有下行风险的ACO 在2019年面临合同续签-六个续签，六个没有。我们将进行半结构化 与主要利益相关者进行电话访谈，以更好地了解影响其参与决策的因素 以及他们的决定如何影响他们改善护理协调和人口健康的努力。2)到 评估MSSP退出对老年患者临床质量和成本的影响。我们将分析 国家医疗保险索赔（2008年至2022年），并确定与MSSP一致的按服务收费受益人。其中 受益人，然后我们将衡量他们的医疗质量和成本（基于CMS要求的结果， 流程指标和总价格标准化的医疗保险支出）之前和之后的路径，以 成功3)评价继续参与研究对老年患者造成的非预期后果。 对于目标2中确定的仍在MSSP中的ACO，我们将评估他们是否参与有利的 患者选择我们还将根据CMS要求和非CMS要求来衡量他们的组织绩效。 在启动“成功之路”之前和之后所需的成果和流程指标。冲击的结果 我们的研究将为政策制定者提供可操作的见解，因为他们将下行风险纳入先进的 支付模式，并为正在考虑组织下一步的ACO利益相关者提供信息。

PROJECT SUMMARY Older patients receive fragmented healthcare that is of variable quality and cost. To address this problem, the Centers for Medicare & Medicaid Services (CMS) developed accountable care organizations (ACOs). ACOs create incentives for providers to work together, while being mindful of their spending. Evaluations of the Medicare Shared Savings Program (MSSP)—CMS’s largest ACO initiative—show that participating organizations have improved care quality for older patients. Nonetheless, their costs remain high because they do not have enough “skin in the game.” The majority of ACOs have contracts in which they share a small percentage of the savings with Medicare when they reduce their annual costs below a benchmark but are not penalized if they fall short (i.e., they have no downside risk). Without the financial threat of downside risk, ACOs have less reason to innovate and increase efficiency. Thus, CMS announced “Pathways to Success” in December 2018, requiring current MSSP ACOs to shift to downside risk in as little as one year. However, shifting so quickly may be detrimental. The MSSP is voluntary, and many ACOs that have engaged in meaningful care redesign may not be ready to take on the possibility of having to repay CMS millions and leave the program instead. Indeed, 40% of ACOs facing contract renewal this July dropped out. Without the potential for shared savings, exiting ACOs may divest their data systems and coordination capabilities needed for population health management, which are costly to maintain. In turn, the ACOs’ patients may suffer lower care quality and higher costs. The decision to stay in the MSSP may have unintended consequences, too. ACOs may pursue cost-containment strategies like favorable patient selection. They may also limit their focus to CMS-required metrics (at the expense of other clinically important ones). These moves would hurt older patients who stand to gain the most from ACOs. In this context, we propose a combined qualitative and quantitative study with three Specific Aims. 1) To examine decisions around MSSP participation and the impact that these decisions have on an organization’s approach to care delivery after launch of Pathways to Success. Using administrative data, we will purposefully sample 12 ACOs without downside risk that faced contract renewal in 2019—six that renewed and six that did not. We will conduct semi-structured phone interviews with key stakeholders to better understand what factors influenced their participation decision and how their decision is affecting their efforts to improve care coordination and population health. 2) To assess the effects of MSSP exit on clinical quality and costs among older patients. We will analyze national Medicare claims (2008 to 2022) and identify MSSP-aligned fee-for-service beneficiaries. Among these beneficiaries, we will then measure their healthcare quality and costs (based on CMS-required outcome and process metrics and total price-standardized Medicare spending) before and after launch of Pathways to Success. 3) To evaluate for unintended consequences on older patients from continued participation. For ACOs identified in Aim 2 that remain in the MSSP, we will evaluate whether they take part in favorable patient selection. We will also measure their organizational performance against CMS-required and non- required outcome and process metrics before and after launch of Pathways to Success. Impact. Findings from our study will provide policymakers with actionable insights as they incorporate downside risk into advanced payment models and serve to inform ACO stakeholders who are considering organizational next steps.